Provider Demographics
NPI:1205697315
Name:MERRICK, MONTANNA LEE (PA-C)
Entity type:Individual
Prefix:
First Name:MONTANNA
Middle Name:LEE
Last Name:MERRICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MONTANNA
Other - Middle Name:LEE
Other - Last Name:CHRYSTAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4811 KESTER ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-2085
Mailing Address - Country:US
Mailing Address - Phone:307-274-6576
Mailing Address - Fax:
Practice Address - Street 1:4003 RAWLINS ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-1800
Practice Address - Country:US
Practice Address - Phone:307-632-1114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPA1221363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant